Exam 2 - HAI & Antibiotics (Grayson's) Flashcards
Out of the 6 sources of hospital-acquired infections mentioned in lecture, select the top 2 culprits.
A. central line associated sepsis
B. c-diff
C. Ventilator-associated PNA
D. CAUTI
E. Hospital-acquired PNA
F. surgical site infections
E. HAP - 22%
F. SSI - 22%
the others:
- Central line associated sepsis
- CAUTI 13% - try to avoid foleys
- VAP - try to keep resp drive as much as possible
- C-diff 12%
T/F: Gloves alone do not prevent contamination.
True, that’s why handwashing is our best measure to reduce # of pathogens!
What bacteria is found on your skin flora that can migrate along the length of a catheter?
A. Coagulase-negative staphylococci
B. Coagulase-negative staphylococci aureus
C. Coagulase-positive staphylococci
D. Coagulase-positive staphylococci aureus
A. Coag neg staphylococci
What labs can be useful to detect organ dysfunction?
- Lactic acid
- PT
- Bun/Cr
- WBCs elevated
- Blood glucose (hypo or hyperglycemia!)
- Cultures = most precise!
Surgical site infections typically occur within ____ days of surgery.
30
Describe the 3 different types of incisional surgical site infections (superficial, deep, organ/space)
- Superficial = skin & subq
- Deep = fascia & muscle
- Organ/Space = any area other than skin and muscle
What are the three most common types of bacteria associated with surgical site infections?
- Staphylococcus
- Streptococcus
- Pseudomonas
How would a wound that is not inflamed or contaminated and does not involve internal organs be categorized?
Clean
How would a wound that has no outward signs of infection but does involve internal organs be categorized?
Clean-Contaminated
How would a wound that involves internal organ infection along with spillage of contents into surrounding tissue be categorized?
Contaminated
What is an example of contaminated SSI?
Ruptured appendix
How is a Dirty SSI defined?
Known infection at the surgical site at the time of the surgery.
ex: trauma, MVC, stab wound…usually will come with ABX already
What are risks factors for SSI?
- > 2hr surgery
- Comorbidities (smoker, DM, cancer, obese, etc)
- Elderly
- Emergency surgery
- Abdominal surgery
Potentially ___% of SSI’s are preventable.
50%
What is a category 1A recommendation?
1A = Strongly recommended; moderate to high quality of evidence
What is a category 1B recommendation?
1B = Strongly recommended; low quality evidence
What is a category 1C recommendation?
1C = Strong recommendation based on state/federal regulation
What is a category II recommendation?
Weak recommendation
What are the recommendations for parenteral antibiotics? Are they 1A, 1B, or 1C recommendations?
1B - Administer only when indicated
1B - Time so that agent is active on tissue incision
What’s the recommendation for non-parenteral (ointments) antibiotics? Is it 1A, 1B, or 1C?
1B - no antibiotic ointment on incision
Dry incisions are better.
What recommendations are there for antibiotic irrigation and prosthetic soaking in antibiotic solution?
No recommendations on prosthetic soaking in abx solution or abx irrigation
What are the 1A recommendations for glycemic control? Select 2
A. Control of glucose preoperatively and recheck in post op
B. Perioperative control of glucose
C. Target glucose < 150 mg/dL
D. Target glucose < 200 mg/dL
B. Perioperative control of glucose
D. Target glucose < 200 mg/dL
What is the recommendation level for A1C targets?
No recommendation for A1C target
Just acute control of BG.
Maintaining perioperative normothermia is a ___ recommendation.
1A
What is the 1A recommendation for oxygenation in GETA patients?
↑ FiO₂ w/ GETA patients w/ normal pulmonary function.
Recommendation is losing credibility as a way to prevent SSI’s.
What are the recommendations for antiseptic prophylaxis?
1A - Intraoperative skin prep w/ alcohol-based antiseptic.
1B - Shower or bathe w/ soap/antiseptic the night before surgery.
II - Consider intraoperative Iodine irrigation.
What is the recommendation for blood transfusion?
1B - Do not withhold necessary blood transfusions as a means to prevent SSI.
Should systemic corticosteroids be utilized in a patient with joint arthroplasty?
Uncertain benefits/harm.
Infection is most common indication for TKA revision however.
What does MIC stand for?
Minimum Inhibitory Concentration
What are the 6 general principles of preoperative antibiotic prophylaxis?
- Should be active against common SSI pathogens
- Proven efficacy by clinical trials
- MIC must be achieved
- Shortest possible effective course
- New ABX reserved for resistant infections
- If possible, use oldest/cheapest ABX
ABX should be initiated within ____ hour of incision.
1 hour
___ and ___ can be initiated within 2 hours of incision.
Vancomycin and Fluoroquinolones (cipro + levaquin)
Can antibiotics be held for cultures?
yes
ABX must be completely infused prior to ____.
A. induction
B. administration of a volatile
C. use of a tourniquet
D. emergence
C. use of a tourniquet
When is re-dosing of antibiotics necessary? select 3.
A. per surgeon request
B. 2 half-lives
C. upon arrival to PACU
D. q2-4 hrs while in OR depending on abx
E. when sterility field is breached
F. excessive blood loss
B. 2 half-lives
D. q2-4 hrs while in OR depending on abx - ANCEF if q4h while Ampicillin is q2h!
F. excessive blood loss - since will leave circulation too quickly, and also CPB
What are the 3 Beta-lactam drug classes?
A. carbapenems
B. penicillins
C. aminoglycosides
D. metronidazoles
E. cephalosporins
F. fluoroquinolones
A. Carbapenems
B. Penicillins
E. Cephalosporins
Resistance to penicillins is due to:
A. proteins altering their structure
B. beta lactam rings binding to PCN-binding protein
C. penetration thru BBB
D. beta lactamase enzyme on outer surface of cytoplasmic membrane
D. beta lactamase enzyme on outer surface of cytoplasmic membrane
Penicillins are the drug of choice for what pathogens? select 2.
A. mostly gram (-) bacteria
B. mostly gram (+) bacteria
C. enterobacter
D. pseudomonas aeruginosa
E. streptococci, meningococci, and pneumococci
F. MRSA
B. Gram + bacteria (Cocci)
E. Streptococci, Meningococci, Pneumococci
Which type of infections might penicillin be useful for? select 3.
A. catheter
B. resistant UTIs
C. skin
D. intra-abdominal
E. upper respiratory infections
F. endocarditis
A. catheter
C. skin
E. upper respiratory infections
List the 4 examples of penicillins mentioned.
- Penicillin G
- Methicillin
- Nafcillin
- Amoxicillin
What are common adverse reactions to penicillins? select 3.
A. hypersensitivity
B. GI upset with large doses
C. production deficit of vitamin K
D. colitis
E. vaginal candidiasis
F. injection site reactions
A. hypersensitivity (incl. anaphylaxis!!)
B. GI upset with large doses
E. vaginal candidiasis
Which class of Beta-Lactams is more stable against beta lactamases (and doesn’t form as much resistance b/c of this)?
A. carbapenems
B. penicillins
C. cephalosporins
D. aminoglycosides
C. Cephalosporins - instead, resistance occurs by a protein altering its structure..
Cephalosporins are the drug of choice for: select 2.
A. bone/jone infections
B. MRSA endocarditis
C. patients with a PCN allergy
D. surgical prophylaxis
C. PCN allergy patients (except true anaphylaxis!)
D. Surgical prophylaxis - Ancef!
What cephalosporin is noted for treatment of gonorrhea?
A. cefoxitin
B. cefazolin
C. cefepime
D. ceftriaxone
D. ceftriaxone (Rocephin)
left from last years class
What cephalosporins do not cross the blood-brain barrier?
Generation 1: Cefazolin
Generation 2: Cefuroxime, Cefoxitin, Cefotetan
Which cephalosporin penetrates the blood-brain barrier well and is usually reserved for multi-resistant organisms?
A. Ancef
B. Maxipime
C. Rocephin
D. Mefoxin
B. maxipime aka cefepime
most resistant to hydrolysis by lactamases
List the three 3rd-generation cephalosporins.
cefotaxime (Claforan)
ceftriaxone (Rocephin)
ceftazidime (Fortaz)
What drugs should be used if true anaphylaxis to penicillin exists? select 2.
A. vancomycin
B. clindamycin
C. neomycin
D. gentamycin
A. vancomycin
or
B. clindamycin
Your coagulopathic patient requires a prophylactic antibiotic for their surgery today. Which class of antibiotics should you avoid as this may cause a production deficit of vitamin K?
A. fluoroquinolones
B. aminoglycosides
C. cephalosporins
D. carbapenems
C. cephalosporins
This antibiotic is a common cause of colitis:
A. cefazolin
B. cefoxitin
C. cefepime
D. ceftriaxone
D. ceftriaxone (Rocephin) - or any 3rd gen cephalosporin
so also cefotaxime, or ceftazidime
Carbapenems have good activity against: select 2.
A. pseudomonas aeruginosa
B. enterobacter
C. bone/joint infections
D. streptococci
E. c-diff
A. Pseudomonas aeruginosa
B. enterobacter
gram (-) rods!!!
Which β-lactam drug class has the broadest spectrum of activity and can inhibit the β-lactamase enzyme?
A. cephalosporins
B. penicillins
C. aminoglycosides
D. fluoroquinolones
E. carbapenems
E. Carbapenems
Carbapenems are typically last line agents for:
A. pneumonia
B. resistant UTIs
C. intra-abd infections
D. c-diff
E. all of the above
F. all but D
F. all but D - so intra-abdominal, resistant UTIs, and pneumonia
cdiff is metronidazole
List the 3 carbapenems mentioned in class.
- Ertapenem (Invanz)
- Meropenem (Merrem)
- Imipenem (Primaxin)
What do IM formulations of carbapenems contain that may be the cause for injection site reactions?
A. epinephrine
B. normal saline
C. dextrose
D. lidocaine
D. Lidocaine
Consider LA allergies prior to IM administration!
Carbapenems must be avoided in patients taking:
A. Flagyl
B. Depakote
C. Eliquis
D. Disulfiram
B. Valproic Acid (Depakote); b/c carbapenems decrease depakote levels in blood up to 90% which precipitate seizures
Vancomycin inhibits cell wall synthesis and works well against: select 2.
A. gram (+) bacteria
B. gram (-) bacteria
C. UTIs
D. URIs
E. endocarditis caused by MRSA
F. fungal infections
A. gram (+) bacteria - too large to penetrate gram (-)
E. endocarditis (and blood stream infections!) caused by MRSA
What are some common adverse reactions to vancomycin? select 2.
A. steven johnson syndrome
B. “red man” syndrome
C. diarrhea
D. ototoxicity
E. nephrotoxicity
B. “red man” syndrome
E. Nephrotoxicity - this is why we check their peak and troughs so often!
and:
chills, fever, phlebitis at inj site
Aminoglycosides (like gentamycin) work by inhibiting:
A. DNA protein synthesis
B. ribosomal proteins which cause mRNA to misread
C. beta lactamase enzyme
D. beta lactam rings
B. Inhibition of ribosomal proteins and cause mRNA misreading
Aminoglycosides (like gentamycin) are synergistic with: select 2.
A. beta lactams
B. vancomycin
C. levaquin
D. metronidazole
A. beta lactams
B. vancomycin
useful for enterococcal endocarditis!!!
What are the adverse reactions associated with aminoglycosides (like gentamycin)? select 2.
A. curare-like effect
B. neurotoxicity
C. ototoxicity
D. prolonged QT interval
A. Curare-like affect
C. Ototoxicity - rmbr her story about this one lol
AND: Nephrotoxicity (in elderly, if used for more than 5 days, renal dz, high doses, concurrent use w/ loop diuretics)
left from last-years class…
Explain the curare-like effect of gentamycin (aminoglycoside).
Gentamycin can interfere with ACh receptors and potentiate effects of NMB drugs.
left from last years class..
What is the treatment for curare-like effects from gentamycin?
Ca⁺⁺
Fluoroquinolones work by inhibiting DNA protein synthesis. They work well against: select 3.
A. bacterial diarrhea
B. bone/joint infections
C. gram (-) organisms
D. gram (+) organisms
E. vaginitis
F. intra-abd infections
A. bacterial diarrhea
B. bone/joint infections
C. gram (-) organisms
List the 2 fluoroquinolones mentioned in class.
- Ciprofloxacin (Cipro)
- Levofloxacin (Levaquin)
rmbr: give these and vancomycin within 2 hrs of incision
What are the adverse reactions to remember for fluoroquinolones (cipro, levaquin)? select 2.
A. peripheral neuropathy
B. cartilage damage/tendon rupture
C. ototoxicity
D. QT prolongation
E. curare-like effect
B. cartilage damage/tendon rupture
D. QT prolongation
What factors will exacerbate cartilage damage and tendon rupture associated with fluoroquinolones?
A. concurrent steroid use
B. concurrent loop diuretic use
C. liver failure
D. renal insufficiency
E. advanced age
F. children < 12
A. concurrent steroid use
D. renal insufficiency
E. advanced age
Metronidazole works by:
A. forming toxic byproducts that destabilize bacterial DNA
B. inhibiting beta lactamase
C. causing mRNA to be misread
D. inhibiting cell wall synthesis
A. forming toxic byproducts that destabilize bacterial DNA
What is metronidazole (Flagyl) indicated for? select 3.
A. otitis media
B. bone-joint infections
C. c-diff
D. vaginitis
E. intra-abd infections
F. strep throat
C. c-diff
D. vaginitis
E. intra-abd infections
What should a patient avoid if taking metronidazole?
A. zofran
B. EtOH
C. benzodiazepines
D. SSRIs
B. EtOH - causes a Disulfiram-like effect!
(like bad hangover sx: flushing, dizziness, HA, chest/abd pain)
What is an adverse reaction with prolonged use of metronidazole?
A. ototoxicity
B. nephrotoxicity
C. peripheral neuropathy
D. curare-like effect
C. peripheral neuropathy
What is (essentially) the first line antibiotic of choice for surgical prophylaxis?
Dose?
cefazolin (Ancef)
< 80 kg: 1 G
80-120 kg: 2 G
Greater than 120 kg: 3 G
left from last years class..
What is the most common alternative to cefazolin for surgical prophylaxis?
Clindamycin (or vancomycin)
